Eisenmenger's syndrome + HF + Heart sounds Flashcards
What is eisenmenger’s syndrome?
Reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension
Why does Eisenmenger’s syndrome occur?
Uncorrected left-to-right leads to remodeling of the pulmonary microvasculature, eventually causing obstruction to pulmonary blood and pulmonary hypertension
What is Eisenmenger’s syndrome associated with?
- Ventricular septal defect
- Atrial septal defect
- Patent ductus arteriosus
What are the features of Eisenmenger’s syndrome?
- Original murmur may disappear
- Cyanosis
- Clubbing
- Right ventricular failure
- Haemoptysis, embolism
What is the management of Eisenmenger’s syndrome?
Heart-lung transplantation
What is acute heart failure?
- Life-threatening emergency
- Sudden onset or worsening of the symptoms of heart failure
- May present with or w/o background history of pre-existing heart failure
- AHF without a past history of heart failure = de-novo AHF
- Decompensated AHF more common (66-75%)
:. presents with a background history of HF
When does acute HF present?
- presents after the age of 65-years
- major cause for unplanned hospital admission in such patients
What is the pathophysiology of AF?
- reduced cardiac output that results from a functional or structural abnormality
What causes de-novo HF?
- Increased cardiac filling pressures and myocardial dysfunction usually as a result of ischaemia
:. reduced cardiac output :. hypoperfusion :. pulmonary oedema
What are less common causes of de-novo HF?
- Viral myopathy
- Toxins
- Valve dysfunction
What are causes of decompensated HF?
- Acute coronary syndrome
- Hypertensive crisis
- Acute arrhythmia
- Valvular disease
What are the signs of decompensated heart failure?
- There is generally a history of pre-existing cardiomyopathy
- Fluid congestion
- Weight gain
- Orthopnoea
- Breathlessness.
What groups are AHF patients characterised into?
- With or without hypoperfusion
- With or without fluid congestion
What are the signs and symptoms of AHF?
What is the BP of AHF patients?
Over 90% of patients with AHF have a normal or increased blood pressure (mmHg)
What is the diagnostic workup for patients with AHF?
- Blood tests – anaemia, abnormal electrolytes or infection.
- Chest X-ray – pulmonary venous congestion, interstitial oedema and cardiomegaly
- Echocardiogram – this will identify pericardial effusion and cardiac tamponade
- B-type natriuretic peptide – raised levels (>100mg/litre) indicate myocardial damage and are supportive of the diagnosis.
What is the management of AHF?
- Oxygen
- Loop diuretics
- Opiates
- Vasodilators
- Inotropic agents
- CPAP
- Ultrafiltration
- Mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices
Consideration should be given to discontinuing beta-blockers in the short-term.
What are the features of CHF?
- Dyspnoea
- Cough: may be worse at night and associated with pink/frothy sputum
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Wheeze (‘cardiac wheeze’)
- Weight loss (‘cardiac cachexia’): occurs in up to 15% of patients May be hidden by weight gained secondary to oedema
- Bibasal crackles on examination
- Signs of right-sided heart failure:
- raised JVP
- ankle oedema
- hepatomegaly
What drugs have been shown to improve mortality in patients with CHF?
- ACE inhibitors
- Spironolactone
- Beta-blockers
- Hydralazine with nitrates
What is the management of CHF?
- Offer annual influenza vaccine
- Offer one-off pneumococcal vaccine (adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years)
What is the NYHA classification for HF?
NYHA Class I
- no symptoms
- no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
NYHA Class II
- mild symptoms
- slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
NYHA Class III
- moderate symptoms
- marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
NYHA Class IV
- severe symptoms
- unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
What causes S1?
- closure of mitral and tricuspid valves
- soft if long PR or mitral regurgitation
- loud in mitral stenosis
What causes S2?
- closure of aortic and pulmonary valves
- soft in aortic stenosis
- splitting during inspiration is normal
What causes S3?
- caused by diastolic filling of the ventricle
- considered normal if < 30 years old (may persist in women up to 50 years old)
- heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation
What causes S4?
- May be heard in aortic stenosis, HOCM, hypertension
- Caused by atrial contraction against a stiff ventricle
- Therefore coincides with the P wave on ECG
- In HOCM a double apical impulse may be felt as a result of a palpable S4
Where to auscultate for pulmonary valve?
Left second intercostal space, at the upper sternal border
Where to auscultate for aortic valve?
Right second intercostal space, at the upper sternal border
Where to auscultate for mitral valve?
Left fifth intercostal space, just medial to mid clavicular line
Where to auscultate for tricuspid valve?
Left fourth intercostal space, at the lower left sternal border
What are the causes of a loud S1?
- mitral stenosis
- left-to-right shunts
- short PR interval, atrial premature beats
- hyperdynamic states
What are the causes of a quiet S1?
- Mitral regurgitation
What are the causes of a loud S2?
- hypertension: systemic (loud A2) or pulmonary (loud P2)
- hyperdynamic states
- atrial septal defect without pulmonary hypertension
What are the causes of a soft S2?
aortic stenosis
What are the causes of a fixed split S2?
atrial septal defect
What are the causes of a widely split S2?
- deep inspiration
- RBBB
- pulmonary stenosis
- severe mitral regurgitation
What are the causes of a reversed (paradoxical) split S2 (P2 occurs before A2)?
- LBBB
- Severe aortic stenosis
- Right ventricular pacing
- WPW type B (causes early P2)
- Patent ductus arteriosus
